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|Member Profile - Hedva Levy|
Hedva Barenholtz Levy
Senior Care Pharmacy Profile
This practitioner provides individualized consulting to seniors to promote the safe and effective use of medication.
This is one in an occasional series of member profiles. All pharmacists were asked to provide answers to several questions. This was originally published in the July, 2004 issue of The Consultant Pharmacist.
Reviewing Drug Regimens by Appointment
Hedva Barenholtz Levy, PharmD, CGP, has established a successful private consulting practice in St. Louis, Missouri, in which she reviews drug regimens of older people at senior centers or in their homes.Working by appointment, she examines their medications, probes their concerns, and provides detailed written feedback to help them discuss important issues with their physicians. Some of Levy’s clients are private-pay; she also is paid under contract with the area agency on aging, which offers free medication reviews to local seniors. “My target population is independent,” Levy explains. “Most live on their own, or maybe in a retirement complex that offers some help, but generally they are not in assisted living facilities or nursing homes.”
Levy’s practice, HbL Pharma Consulting, combines her love of drug information and her interest in older people. It also allows her flexibility while she raises two sons, ages three and five. She allocates her professional time to meet her own schedule, often researching medical information and drug issues at night or on weekends to compile the reports she sends patients and their physicians.
Valuable Services for Seniors
“We hire her because her services are very valuable,” says Stefany Brot, coordinator of special projects at the Mid-East Area Agency on Aging. Brot pays Levy to meet with clients at local senior centers two days a month, using funds allocated for health promotion and disease prevention through the federal Older Americans Act. “If you think it through, you realize it’s cheaper to keep [individuals] in their homes and give them help like this than it is to pay for a nursing home,” Brot notes. “And, if you have people with diabetes who are not taking their medications, they will end up in a nursing home.”
Ann Bannes, vice president of community services at St.Andrews At-Home Services, sends referrals to Levy when she encounters seniors with medication-related problems. “We’re a private agency providing supportive services to older adults and their family caregivers,” Bannes explains. “Through the years, as we’ve identified various needs, we’ve created a select provider network of competent, credible professionals, and Hedva is part of that network.”
When asked how often she finds that older adults require the type of services Levy offers, Bannes replies, “Almost all the time.”
Levy’s training includes a PharmD from the University of Michigan and a bachelor’s degree in sociology. She earned the two simultaneously because she wanted a well-rounded education extending beyond science and health care. “It’s interesting how my sociology background really permeates the work I do,” Levy says. “I’m fascinated by the ways people work together.”As a college student she developed an interest in geriatrics when she realized that some of her aging grandmother’s health problems had been overlooked. “I saw how older people fall through the cracks and are not taken care of as well as they should be.” Levy also completed a one-year clinical pharmacy residency at Shands Hospital in Gainesville, Florida, and became certified as a pharmacotherapy specialist (BCPS) and certified geriatric pharmacist (CGP).
Before launching HbL Pharma Consulting in 1996, Levy worked as a clinical coordinator at a community hospital outside of Cincinnati and served as assistant editor for The Annals of Pharmacotherapy, both of which honed her skills in teaching, writing, research, and interpersonal relations.
A Practice Built Through Networking
Levy’s transition to private consulting coincided with her move to St. Louis, where her physician husband joined an ophthalmology practice. “I came here knowing what I wanted to do, and I started out by networking,” Levy explains. “I went to the library and researched the resources on aging and retirement communities. I learned about case management, geriatric care managers, elder service providers, and area agencies on aging. I did a ZIP code search and looked through the business journal to identify contacts, and I started getting in touch with them.” In the meantime she developed a brochure to promote her services and attended a seminar on how to start and manage a small business, offered by SCORE, a nonprofit association that provides entrepreneurial education and counseling. “I didn’t even know such a thing as a business plan existed before that,” Levy says.The seminar jump-started her efforts and helped focus her business goals and mission.
“One day I saw a press release about somebody doing home care for seniors,” Levy notes. “I called that person, and next thing I know she invites me to a meeting with a marketer for a comprehensive geriatric care management organization.” Now one of her greatest sources of networking and referrals is the Breakthrough Coalition, a group of elder care agencies and individuals that meets every other month in an effort to enhance the lives of seniors in the St. Louis area.
The tagline on Levy’s Web site describes her practice as “an individualized consulting service to promote the safe and effective use of medication.” Her writing and communications skills are apparent on the site, which was professionally designed. Readers can quickly understand what Levy does and who may benefit because the information is so clear and readable.
In Levy’s practice model—which she describes as “patient-focused”— seniors fill out a short “Medication- Risk Questionnaire” to help pinpoint key issues (see sample, page 599).The questionnaire is designed to raise seniors’ consciousness about medication- related problems they may not realize they have.Additionally, it helps Levy prioritize appointments with those who sign up for free sessions through the Mid-East Area Agency on Aging. “Stefany really talks up the service and sometimes there is tons of interest,” Levy says. “On the other hand, some people are skeptical; they don’t want to do it.They say,‘Why do I need that? My doctor takes care of everything.’”
During the 45-minute appointments, Levy asks questions to flesh out the client’s medical history. She also examines each medication bottle, which she has found is a far more reliable source of information than lists, because lists sometimes are outdated or incomplete, or the client’s memory is imprecise. “After about 30 minutes I turn the information around and start making suggestions,” Levy explains. “If there is something I can fix or adjust on the spot, I try to do it.” She not only evaluates medication issues, but also reviews nondrug therapies, untreated problems, herbal remedies, and vitamins.A few days later she sends the client a detailed letter, roughly two pages long, explaining her recommendations. With the client’s permission she mails a copy to his or her physician. “Before I write the letter I do thorough research to access the most current information, searching the medical literature online to find information about interactions and scientific studies.”
Appointments are typically part of a one-time consultation, although patients with more serious issues may schedule follow-up visits.At the senior centers, sometimes clients request follow-up sessions simply for reassurance that everything is okay. Levy encourages clients to call her with questions after they read her report, and sometimes they do. Levy also phones to check on them if she has specific concerns. “When I meet with them I ask,‘Who helps you? Who else is involved, keeping an eye on things for you?’ I want to make sure they have support.”
In sending copies of her reports to physicians, Levy encourages questions and feedback. She doesn’t call the physician, however, unless there is a pressing need. “My letter is focused toward patient education,” she explains. “For one thing, I don’t have access to patients’ medical information and I am working with what they give me.My hope is that the letter will focus the doctor’s eyes on medication issues.”A weakness of her approach, Levy acknowledges, is that she has no consistent way to learn whether a physician has implemented her recommendations. “My gut feeling is that there are changes made, not necessarily in the first month after they get my letter; it may take six months.” She says she has never received negative feedback from a physician about her recommendations. Patients generally are extremely grateful for her information.
“I strive to empower patients,” Levy says. “That generation in the 70-plus age range doesn’t question the doctor— they are afraid to bother him. I think my information makes it easier for patients to ask questions without feeling that they are challenging the doctor.”A typical report to patients will explain what a drug is prescribed for, mention possible side effects relevant to a person’s age and condition, suggest nondrug ways to improve his or her condition, and highlight matters to clarify with the physician, such as whether changing to a different medication might reduce side effects. Recommendations might include, “Consider asking your doctor to refer you to a dietitian to help develop meal plans to better manage your diabetes,” or “The nitroglycerin tablets in your house have an expiration date of over 12 months ago. These tablets are likely no longer effective. You need to speak with your doctor as soon as possible to ask if you still need to have this drug for emergencies.”
Sometimes adult children make the appointment for a parent, as happened with a 79-year-old woman on 11 medications whose mental status was deteriorating. “The son had been displeased with the doctor’s quality of care,” says Levy, who made several recommendations, including suggesting a re-evaluation of the drug prescribed to treat her irritable bowel syndrome and of two medications considered potentially inappropriate in the elderly. In contrast with that there was a 70-year-old woman who said she took “only one prescription drug,” but decided to see Levy anyway, since her appointment at the senior center was free.Though her prescription was for osteoporosis, she did not get sufficient calcium daily. Levy also discovered that the woman recently had been diagnosed with an ulcer, but was taking her medication as needed and didn’t know if her doctor had tested for H. pylori, which could have been treated by antibiotics. “Turns out we had plenty of important issues to discuss,” Levy says.
The most challenging aspect of her practice, Levy says, is boosting the public’s awareness of the need for medication reviews in the elderly. “I hear people say,‘If I’d known about you a month ago it would have made a big difference.’” Levy says she feels frustrated to think she could have helped avoid a hip fracture or some other problem. “But when there’s no crisis, people tend not to realize it would be a good idea to have a pharmacist look at their medications,” Levy says. Her “Medication-Risk Questionnaire” is modeled after the brief self-assessments in magazines that alert people to their risk for heart disease, diabetes, or other conditions. “My major focus is how to get people to understand they need this service.”
Levy is “a pioneer in the field,” says Bannes. She says her agency gets people with multiple health problems and multiple medications, but is concerned that no one is evaluating their medications. “Managing medications is not as simple as writing on a script, ‘Take three times a day.’” she says. “Does somebody sit down with people and go over everything? Do they ask an old person,‘How are you feeling?’ Are they considering whether emotional or mental changes have to do with medications?” Bannes is impressed by Levy’s professionalism and high standards. Levy’s demeanor, too, is very effective with the elderly, Bannes says. “She’s calm, low-key, and soothing, which helps to build trust. The older people love her. Half the time they don’t tell you all that’s going on, but Hedva breaks through that barrier.”
“Hedva is one of the best parts of our program,” says Brot. “She listens to clients’ fears, she checks how they are storing their medications, she gets into diet and caffeine. So often she finds that seniors aren’t taking their medications the way they should be.”